Patient COVID-19 Safety Screening Form

Personal Information

COVID-19 Vaccination

Have you been vaccinated against COVID-19?

If you have been vaccinated against COVID-19, has it been at least two weeks since you received the second dose of the Pfizer or Moderna vaccines or the single dose of the Johnson & Johnson vaccine?

If you are not fully vaccinated against COVID-19, you must show proof of a negative test result from within the last 72 hours.

COVID-19 Symptoms

Have you experienced any of the following symptoms today or yesterday?

  • Cough
  • Sore Throat
  • Muscle Pain
  • Headache
  • Diarrhea
  • Shortness of Breath
  • Difficulty Breathing
  • Weak or Fatigued
  • Loss of Taste
  • Loss of Smell
  • Runny Nose
  • Nasal Congestion
  • Itchy Toes
  • Itchy Fingers

COVID-19 Testing & Diagnosis

Have you been diagnosed with COVID-19 in the preceding 10 days?

Do you live in the same household with or have you had close contact with someone who was diagnosed with COVID-19 or tested positive for the virus in the last 14 days?

Have you had a COVID-19 test in the past 3 days?

Sign & Date